The CCMC’s final report summarized its earlier findings and recommendations, but it added a new fifth recommendation that would be the final nail in the coffin of the Committee’s work: Education. The CCMC believed a group practice model would wholly or in part eliminate the problems of the fee for service system by having better coordination between the primary care doctor and the specialist, assuring better quality care, reducing duplicative overheads and equipment, and reducing complexity of care.
Recommendation 1: Organization of Medical Services:
“The Committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel. Such groups should be organized, preferably around a hospital, for rendering complete home, office and hospital care. The form of organization should encourage the maintenance of high standards and the development or preservation of a personal relation between patient and physician. (CCMC op.cit. 109).
While the final chapter includes minority comments in footnotes, they will be covered in the next installment.
Community Medical Centers, it noted, was the most fundamental recommendation to develop hospitals into comprehensive Community medical centers with local branches and rural stations where the medical profession and patient participate in providing care and paying for it. The centers had to have some plan of group payment plan.
It also thought that another ideal model would be paid for jointly by employee and employer. The Report also outlined how some employer models could work, it also discussed how to transition University Medical Services into comprehensive medical centers and how to use subsidiary health care personnel, such as trained nursing attendants for long-term care and advocated wider use of mid-wives.
The Recommendation also included a range of clinics: private group clinics, which could be an extended to become comprehensive medical centers; pay clinics for people who are not indigent, but who could not afford the health care premium and which would be funded by tax dollars, but would be closely linked with other medical centers and a hospital; middle-rate hospital services which would include a fee schedule of all professional and hospital charges, so patients of moderate means had an understanding of the costs and a way to pay for services afterward; private physician offices in hospitals would be a major step in associating general medical services with the facilities they use; organized nursing services should be developed in conjunction with comprehensive health services; county medical society clinics could be successfully implemented in rural areas to provide care for those people unable to pay for professional care services. Care would be paid for by city and county governments.
Recommendation 2: Strengthening of Public Health Services:
“The Committee recommends the extension of all basic public health services—whether provided by governmental or non-governmental agencies—so that they will be available to the entire population according to its needs. Primarily this extension requires increased financial support for official health departments and full-time trained health officers and members of their staffs whose tenure is dependent only upon professional and administrative competence.” (CCMC op.cit.118)
Health officers would be employed by local or state governments, but their work should be independent of political considerations. In addition, the Recommendations listed proper public services which could not necessarily be provided as well by the private sector. The Committee saw public health services as including: the collection and analysis of vital statistics; the control of water, milk and food supplies; control of sanitation; the control, through quarantine, and supervision of communicable diseases; laboratory services; and the promotion of maternal, infant and child hygiene, including the medical and dental inspection and supervision of school children; and popular health instruction. The Recommendation also included the development of a public health nursing service.
Public health was also to have responsibility for diagnosis and treatment of certain conditions, such as tuberculosis, venereal diseases, malaria, hookworm, or any other disease that represented a health threat to the community.
Recommendation 3: Group Payment for Medical Service
“The Committee recommends that the costs of medical care be placed on a group payment basis, through the use of insurance, through the use of taxation, or through the use of both these methods. This is not meant to preclude the continuation of medical service provided on an individual fee basis for those who prefer the present method. Cash benefits, i.e., compensation for wage-loss due to illness, if and when provided, should be separate and distinct from medical services.” (CCMC op.cit. 120)
The Report noted that all the members of the CCMC, with the exception of those who disagreed in the minority report, supported this payment model. Different models were outlined: Voluntary Cooperative Health Insurance in which an organized group of consumers would come together to pay a monthly fee, and work with an organized group of medical practitioners to provide those consumers with complete medical care; Required Health Insurance for Low-Income Groups, some members of the Committee thought the industrial states should immediately begin to prepare legislation to require all individuals in certain income groups and certain occupations and geographic areas to subscribe for health insurance; Aid by Local Governments for Health Insurance was seen as essential to cover the costs for those who could not afford coverage, and essentially recommended a sliding fee scale approach, with support also from local tax dollars. The Committee members felt strongly, however, that as much as possible the individual must participate financially for services received; Salaried or Subsidized Physicians in Rural Areas were seen as necessary in order to assure services were available in rural areas, and tax support from one or more counties might be a way to assure these subsidies; State and Federal Aid was considered to be essential. The state would provide care for the low income, but in states where there were serious public health problems, such as malaria and tuberculosis, services should be paid from federal tax dollars. Supplementary or Temporary Use included such things as Voluntary Hospital Insurance; Tax funds/districts for local hospitals and Tax funds for the indigent and ‘necessitous.’
Recommendation 4: Coordination of Medical Services
“The Committee recommends that the study, evaluation and coordination of medical service be considered important functions for every state and local community, that agencies be formed to exercise these functions, and that the coordination of rural with urban services receive special attention.” (CCMC op.cit. 134)
The Recommendation went on to identify particular steps to do so: Temporary Professional Groups with Lay Participants. The Committee thought that professional health care societies should appoint committees to work together to create models of coordinated care; Permanent Local Coordinating Agencies needed to be created to evaluate and coordinate existing services, eliminate unnecessary services, and stimulate the addition of new and needed services. State Coordinating Agencies should be created as soon as possible to evaluate needs in the various counties and begin to outline and coordinate services and create a state plan. Control of Drugs and Medicines required state and federal legislation to prevent “the sale of drugs and medicines with secret formulas” (CCMC op.cit. 136). The Committee wanted very specific labeling and annual licensing of manufacturers by the federal government.
Recommendation 5: Basic Educational Improvements
“The Committee makes the following recommendations in the field of professional education: (A)That the training of physicians give increasing emphasis to the teaching of health and the prevention of disease; that more effective efforts be made to provide trained health officers; that the social aspects of medical practice be given greater attention; that specialties be restricted to those specifically qualified; and that postgraduate educational opportunities be increased; (B) that dental students be given a broader educational background; (C)that pharmaceutical education place more stress on the pharmacist’s responsibilities and opportunities for public service; (D) that nursing education be thoroughly remoulded to provide well-educated and well-qualified registered nurses; (E) that the less thoroughly trained but competent nursing aides or attendants be provided; (F) that adequate training for nurse-midwives be provided and(G) that opportunities be offered for the systematic training of hospital and clinic administrators.” (CCMC op.cit. 138)
Specifically, Preventive Medicine in Private Practice “Future Medicine, the Committee believes, will be concerned increasingly with the prevention of disease and defectiveness as well as its alleviation and cure. Medical students, therefore, should be thoroughly instructed in the conduct and use of periodic health examinations, in the basics principles of psychiatry, and in the prevention of specific diseases. Such emphasis should not be confined to special courses in public health or preventive medicine but should, as far as possible, permeate all courses. This involves the reorientation of the entire curriculum.” (CCMC op.cit. 138-139).
Training of Health Officers needed to be expanded because most of the public health schools were largely populated by foreign students, not Americans. The Committee wanted more scholarships and advocated eliminating the apprentice system of public health education. Social Medicine was viewed as an integral part of the practice of medicine. Medicine was seen not just as a biological science, but one that included social, economic, psychological and sociological relationships. This should also permeate the entire curriculum. Specialism “The practice of specialties should be limited to those persons whose training or experience gives them a skill in their field distinctly above that which ought to be possessed by all well-trained general practitioners. According to the Committee’s studies, the real needs of the people call for three to five times as many well-trained general practitioners as specialists; and most schools, therefore, should concentrate their energies on producing well-qualified general practitioners.” (CCMC op.cit. 139-140. Post graduate education should be expanded in order for practicing physicians to keep up with the rapidly expanding body of medical knowledge.
Dental Education: Dental education needed to be expanded as dentistry was seen no longer as just a matter of mechanical maintenance and restoration of teeth, but a profession that was becoming an important part of a patient’s overall health. The dental curriculum should be expanded to include chemistry, anatomy and physiology.
Pharmaceutical Education: The Committee saw many medications as being dangerous and wished to leave the production of medications to pharmacists who had the training to protect the public. Training of pharmacists should be expanded to emphasize their importance in public health.
Nursing Education: The Report blamed hospitals for the oversupply of nurses and recommended an overhaul of nursing education and the nursing curricula so the nursing schools would “produce socially-minded nurses with a preparation basic to all types of nursing services.” (CCMC op.cit. 142).
Training of Nursing Attendants: The Committee thought more trained nursing attendants were needed to help with simple services under the supervision of a visiting graduate nurses, so the attendants can work at lower wages, but provide services from nursing care to housekeeping.
Training of Nurse Mid-wives: The Committee also believed that nurse mid-wives played an important role in the provision of maternity care, especially in rural areas. It advocated for the expansion of schools for mid-wives. (Expansion of mid-wives is of interest, in that in 1927 the AMA had Congress repeal the 1921 Sheppard-Towner Act, which gave matching federal funds to states for prenatal and well child clinics, staffed primarily by public health nurses and women physicians. (Paul Starr, The Social Transformation of American Medicine, 1982, Basic Books, Inc. pg. 260-261).
Training of Administrators: Recognizing that clinic administration is not only technical, but economic, with the expansion of the new committee medical centers, the need for well trained administrators would increase.
The Committee did not advocate replacing or duplicating existing institutions, but rather building and expanding on the foundations of existing programs.
These profoundly strong recommendations on professional education would have completely changed the direction of American medicine. Which may explain why the Report was treated as Rapunzel with a haircut and why the Committee’s 28 research studies are housed in the archives on the top floor of the AMA. (Charles C. Smith, Jr. MD, The Committee on the Costs of Medical Care, Paper Presented to Innominate Society for the Study of Medical History, April 10, 1984).
The Committee completed its report with a call for leadership and action at the local levels. “The outstanding need is for effective leadership. Wars are not won without it.” (CCMC op.cit. 147).
It concludes it report with a sense of urgency, citing more infants died each year (135,845) than the number of Americans killed in battle during WW I (50, 285). (CCMC op.cit. 148)
Their final paragraph is a hauntingly familiar plea. The diseases may have changed, but the needs are no less urgent. These conditions remain today:
“Delay can no longer be tolerated. The death rates from cancer, diabetes, and appendicitis are rising threatenly. More babies are dying each year from, many of them needlessly, than there were American soliders killed in the World War. Every year tuberculosis kills its thousands and costs the country more than half a billion dollars. By early application of our knowledge we could double the cured cases of cancer. The venereal diseases still levy a heavy toll of blindness and mental disorders upon the nation. A great army of rheumatics remains untreated without hope of alleviation or cure. Many diabetics still remain without insulin or receive it too late. Human life in the United States is being wasted, as recklessly, as surely, in times of peace as in times of war. Thousands of people are sick and dying daily in this country because the knowledge and facilities that we have are inadequately applied. We must promptly put this knowledge and these facilities to work.” (CCMC op.cit. 150)
But there was never the leadership at the national or local levels to take on the Report’s vocal critics, as we will see next in the minority report.